Geriatric Medicine:A Brief History

Mary Ann Forciea MDClinical Professor of MedicineDivision of Geriatric Medicine

UPHSJuly 2013

Aging and AntiquityIn Ancient Egypt, median length of life was:

A. 10B. 20C. 30D. 40

A. B. C. D.

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Aging through the AgesRitch JR Col Phys Edin 2012

• Philosophy– Is old age a natural or pathologic condition?– Is old age an illness in its own right?– Is aging unalterable or amenable to control?– Are diseases occurring in old age peculiar to

old people or common at all ages?

300 BCE- 1000 AD

• Hippocrates/Aristotle– Aging resulted from the gradual loss of heat

generation from the body• Increased susceptibility and resistance to disease• “fevers are not so acute in old people”

• Galen– The heat loss of aging could be delayed by

attention to diet and exercise– “Gerocomy”: the care of the aged

Middle ages

• Gradual movement towards old age as a disease– Francis Bacon :ageing due to unequal repair

rates in different organs– Germany – ‘hardening’ of fibers and arteries

• Persistent interest in rejuvenation

Artist: Lucas

Which of the following has NOT been used as a rejuvenation technique?

A. B. C. D. E.

0% 0% 0%0%0%

A. Bathing in breast milk

B. Sex with virgins C. Injections of pig

testicles D. Stem cell injections E. Caloric restriction

Aging and Rejuvenation

• Driving interest through the ages in rejuvenation– Mythology – common concepts:

• Dietary strategies: Bible -tree of life, Gilgamesh-underwater plant of immortality

• Magical waters: Fountain of youth, rivers of youth, bathing in water or milk

• Sexual encounters, especially with virgins

• Hindered real scientific enquiry until the last century

18th/19th Century views

• Rise of ‘science’, pathology• Aged persons died of disease(s)• Benjamin Rush (1793)

– “Few people die of old age”

Geriatric Medicine

• Nacher – 1914 textbook- definition– ‘Geriatrics, from geras, old age,

and iatrikos, relating to the physician, is a term I would suggest as an addition to our vocabulary, to cover the same field that is covered in old age that is covered by the term pediatrics in childhood, to emphasize the necessity of considering senility and its disease apart from maturity and to assign it a separate place in medicine.’

Roots of Geriatric Medicine and Assessment

• In America and Great Britain, care of the Elderly in 3 situations-1700-1940– Their own home or homes of their families– Grouped with the poor (“Poor Homes”)– Grouped with the mentally ill (Asylums)

• Often no evaluation other than economic

Roots 2

• In the period between WW1 and WW2– Increase in professionalism of

• Medicine• Nursing• Social Work

– Large number of young wounded who need chronic care

– Large numbers of conscientious objectors– Increase in numbers of elders

• Led to concept of initial evaluation and specialized care

Great Britain

• Reclassification of Chronic Hospitals• Training in Geriatrics• Post WW2, Geriatricians represented in the

new NHS- 1946 (and creation of BGS)– Networks of care: acute hospital units, home

care services in addition to chronic hospitals• Leader: Marjory Warren

In which type of health facility did Marjory Warren make her initial contribution?

A. B. C. D. E.

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A. Home care (‘home visiting’) program

B. Day hospitalC. Nursing homeD. Acute care hospital

wingE. Village office practice

Initial assessmentMargory Warren 1943

• 1935 – took over responsibility for patients in a ‘chronic sick’ hospital

• Assessed all residents, classified– Chronic up-patients (ambulatory)– Chronic continent bed bound– Chronic incontinent bed bound– Senile, quietly restless(not noisy or annoying)– Senile dementia(noisy and/or annoying)

Warren Recommendations

• Specialized accommodations near Hospitals

• Specialized training for medical students

• Goals:• “These worthy people, whose lives

have been every whit as useful as we would like to believe our own, are ill housed with younger folk who are irritated by them, and in turn annoy them..”

Geriatric Medicine in the US

• History– Facilities– Professional societies– Public policy

When was Medicare established?

A. B. C. D. E.

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A. 1933B. 1946C. 1950D. 1964E. 1972

Which professional society was established first?

A. B. C. D. E.

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A. AMDA B. AGSC. GSAD. AAHCPE. ASGPsyc

US Public Policy Changes

• Civil war1861-65– Chronic hospitals: Walt Whitman– Military pensions

• Social Security Act –1935• Medicare and Medicaid- 1965• Professional Societies

– AGS 1942– GSA 1945

• First ‘Specialty Examination’ 1988

The National Institute on Aging

• Initial efforts– 1940 – Unit on Aging in the Division of Chemotherapy– 1941- Unit moves to Baltimore City Hosp(Nathan

Shock)• Baltimore Longitudinal Study begun in 1958

– 1959-Section on Aging, NIMH (James Birren)– 1974-National Institute on Aging(Robert Butler)

• 1983 T Franklin Williams• 1993 Richard Hodes

Veterans Administration

• 1976 – first grants for Geriatric Research, Education, and Clinical Centers(GRECC)

• 1976 – first fellowships in Geriatric Medicine– Subsequently, fellowships in GeriPsychiatry

• 1980sGeriatric Evaluation and Management Units• 1980s Home Based Primary Care teams• 1980s Teaching Nursing Homes

Significant Foundation/Philanthropic Support

• John A Hartford Foundation– Career Development support– Centers of Excellence– Home care

• Donald W Reynolds Foundations• Bureau of Health Professions

– GACA, GIF, GEC programs

Home care visits

A. B. C. D.

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In what year was the first medical publication about house call practices for geriatric patients appear?

A. 1938B. 1949C. 1955D. 1960

Home Care

• 1949. Martin Cherkasky. The Montefiore Hospital Home Care Program.– Similar in home care as today– Costs: $3/day compared with the inpatient

daily charges of $15/day.

First Description of an Office-based Geriatric Assessment Program

A. B. C. D. E.

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Location:

A. Glasgow, ScotlandB. Baltimore MDC. Boston MAD. Philadelphia PAE. Seattle WA

Fellowship Training in Geriatric Medicine

• 1966 – Leslie Liebow opens first fellowship at Long Island Jewish Hospital– 1967 – first ‘teaching nursing home’

• 1978 – NIA – first post doctoral fellowship awards

• 1982 – first Academic Awards for junior faculty• 1988 –first examination for a Certificate of Added

Qualifications– Jointly offered by ABIM and AAFP

Challenges/Controversies

• Recruitment• Reimbursement

– Team care• Clinical niche

– Academic vitality• Length of training

Geriatric Medicine at the U of Pa

• 1981 – Jerry Johnson – RWJF Scholar– Opens a Geriatric Assessment Unit at VAMC

• Andrea Millman, Jack Coffey• Academic Program within Section of General Medicine

• 1982 – Mary Ann Forciea – NIA Academic Award (Wistar Institute)– Joins VA group

• 1983 – open HUP service– EB Foerderer Geriatric Assessment Program

• Gary Gottlieb, Eileen Sullivan, Annette Harmon

Local History - 2

• Initial programs at both hospitals –– Outpatient assessment and primary care– Unusual at that time

• Second stage – inpatient consult services at both hospitals– Shortly led to inpatient primary care services

• GEM (inpatient Geriatric Evaluation and Management unit) - VAMC

Local History - teaching

• 1984 – first fellows– VA – Patricia Baccash, Raymond Cogen– HUP – RWJF Scholars

• Marian Alessandroni, Risa Lavizzo-Mourey, Gary Gottlieb

Local History - Research

• Vincent Cristofalo PhD– Professor at the Wistar Institute

• Cell Biology of Aging

• Founding Director of the Institute on Aging, University of Pa– Cross ‘Schools’ Center– Triple Mission: foster

• Research, Clinical Care, Teaching

IOA

• First grant: Teaching Nursing Home Award– Initial round – NIA funded– Cooperative with MCP– Second round – MCP leader Ira Katz, MD

• By third round, transformed to Geriatric Education Centers– Schools of Medicine and Nursing

• Mathy Mezey, Neville Strumpf, Lois Evans– 6 rounds of consecutive funding

• Hiatus of federal funding

1990s• Clinical Division Growing

– Faculty recruitment from fellows• Jerry Johnson(RWJ), Mary Ann Forciea(NIA), Edna Schwab, Bruce

Kinosian(Kaiser), Bob Pignolo, Nalaka Gooneratne, Amy Corcoran, Rachel Miller

– Faculty recruitment from outside• Charles Spencer, Jason Karlawish, John Bruza, David Cassaret, Joshua Uy,

Lynsey Brandt– Faculty recruitment from neighborhood

• Lesley Carson, Joan Weinryb, Sefi Knoble, Bill Kavesh, Phil Taylor, Deborah Wei

-NPs:• Kathy Witta, Jean Yudin, Bill Edwards, Johanne Louis, Stephanie Johnson

– Social work• Jeanette Gallagher,

– Research faculty: Ravi Jayadevappa, Gala True

Divisional Growth

• Too large for General Internal Medicine– John Eisenberg, Division Chief

• Divisional Status– Larry Beck – first Section Chief– Truman(Nipper) Schnabel– Risa Lavizzo-Mourey– Jerry Johnson

Clinical Programmatic Growth• First NH relationship

– VACLC– Elmira Jeffries NH

• 5 years• Bill Edwards – NP at Elmira

– Penn Center (‘New Ralston’)– Trial period of faculty expansion into NH Care

• 58th Street, Broomall, Park Pleasant– Continuing Care Retirement Communities

• Pennswood Village, Presbyterian Inspired Life

Inpatient Care

• VA, HUP services – ‘private patients’• UPHS acquires Presbyterian Medical

Center– ACE unit

• 36-bed acute medical/surgical floor• Resident rotation• Close ties to 20-bed SNF unit• Bill Kavesh the initial Medical Director• John Bruza, current Med Director

Home Care

• VA – Home Based Primary Care– Bruce Kinosian, initial Med Director

• Truman Schnabel In-Home Primary Care Program– Jean Yudin, Executive Director– Medical Directors: Genie Siegler, Grace

Cordts, MAF

Day Hospital• School of Nursing – Comprehensive Outpatient

Rehabilitation Program (CARE)– Lois Evans, Joanna Yerkow, Mary Ann Forciea

• Funding discontinued in Washington• Transformed into the LIFE program

– Bruce Kinosian, initial Medical Director– Jean Yudin, Jeanette Gallagher, initial LIFE at home– Charles Spencer, LIFE faculty

Lessons Learned

• Start in area of strongest administrative support– Inpatient services, Outpatient services, Home Care,

Nursing Home practices, Palliative Care

• Add programs with faculty• Negotiate for administrative and research time for

faculty• Ensure collaboration with Nursing, Rehab,

sympathetic consultants

Lessons learned - 2

• Diversify clinical practices• Make sure that revenue counted broadly

– All income generated for system• Admits, referrals, testing

– Watch for shared overhead problems with grants – clarify before submission

• Keep good fellows!

Conclusion

• Assessment is critical to effective care• Geriatrics professionals must

– Master their own discipline– Collaborate with colleagues– Be committed to teaching

It’s a wide, wide world

…in the USA

No place like home

1020304050

Jeopardy – wide world• 10 – In what country did the clinical development

of Geriatric Medicine occur?- GREAT BRITIAN• 20-She published criteria for geriatric assessment

of elderly chronically ill patients M Warren• 30 – This country has the world’s longest mean

lifespan Japan• 40-This country does not have a national system

of health care for the elderly- US• 50-Alois Alzheimer practiced in this country-

Austria

Jeopardy - USA

• 10 – This federal program supports care for the acutely ill elderly-Medicare

• 20 – The 3 disciplines most commonly included in Geriatric Assessment -Medicine, Nursing, SW

• 30-Trainees from these Medical disciplines may sit for the Board Examination in Geriatric Medicine- Int Med, Family Med

• 40-This site of care for older patients has the longest history in the US- Nursing Homes

• 50-The first Director of the NIA- Robert Butler

Jeopardy - Local• 10-This health system sponsored the initial Geriatric

Medicine program at the U of PA - VA• 20- The number of residents trained yearly on the ACE

unit at Penn Presbyterian -78• 30 Name five of the Disciplines(or Schools) participating

in Geriatric Assessment in the past 25 years – Med, Psych, Rheum, Neurology, Podiatry, SW, Nursing, Oral Med

• 40-The location of the furthest geographical practice site of a former fellow of our Division New Zealand

• 50 The name(or acronym) of the first inpatient Geriatric Unit in our Division - GEM

Final Jeopardy

• This US city is the site of the most influential longitudinal study of aging-Baltimore